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IN SEARCH OF THE ELUSIVE

BEHAVIOR THERAPIST

by Fred Penzel, Ph.D.

A question I am frequently asked by those who suffer from OCD and Trich is, "How can I find a behavior therapist near where I live?." It must seem to many people that therapists with this specialty tend to be rather rare and exotic creatures. In truth, there really aren't all that many behavior therapists here in the U.S.. Also, they generally tend to congregate around certain regions and usually near major metropolitan cities. This is, after all, where the greatest number of patients are, and let's face it, behavior therapists have to make a living like anyone else. Don't get too discouraged. There are still a fair number of them scattered around, and graduate programs are turning out more all the time. My purpose in writing this article is threefold: first, to help you locate a therapist of the behavioral persuasion; second, to show you how to question them about their qualifications and services; and third, to give you at least some information so that you will be able to evaluate what they have to offer you.

Where and how to look:

There are several sources of referral information that you will find helpful in your quest, and I will give them to you here.

The Trichotillomania Learning Center (TLC): the obvious place to start. They are the premier organization for those with this disorder. You can call them at (831) 457-1004 for the names of practitioners they know of in your area. Their web address is www.trich.org . and their website is quite helpful and informational.

The International Obsessive Compulsive Foundation (IOCDF): They maintain a large national referral list organized by states, and you can call them to request their listing for yours at (203) 878-5669. There is no guarantee that the OCD specialists they list will also specialize in trich, but they may, or else those whose names they give you may know of other practitioners in your area. Their web address is www.ocfoundation.org

The Association for the Advancement of Behavior Therapy (AABT): A professional organization whose members practice behavioral therapies. While they do not maintain a listing of inch specialists, they do have a list of specialists in OCD which is organized geographically. Again, these specialists are worth calling for the reasons mentioned above. Once again, even if some of these practitioners don not treat trich themselves, they may know other specialists who do. Their website can be found at www.aabt.org

Your local trich or OCD support group (assuming you have one): Attendees are often a valuable source of information, because members may have already seen many of the local practitioners.

University hospital centers that have OCD clinics: There are very few trich treatment centers, and you are better off asking to speak to someone in their OCD program. They may have a trich specialist.

Your county psychological society: This may be a bit of a long shot, depending upon how many members they have, but you never know. They usually list their members by specialties, and may know of a local inch specialist. Sometimes the secretaries at these offices are extremely knowledgeable.

People who staff the organizations listed above are quite helpful and will certainly do their best to help you. Don't be shy about calling them, as they get such calls all the time. As you begin your search, there is one very important point to keep in mind. There is no such thing as the "perfect" therapist. A particular therapist may or may not be the best match for a particular patient depending upon the therapist's style, and the personalities of both individuals. If you are fortunate to live in a location where behavior therapists who specialize in trich are plentiful (Is there such a place?), you will have the luxury of being able to choose from several. My hunch, however, is that you will probably be lucky to have even one such specialist in your area, so you may have to work with them and make the best of it. Hopefully, this person will have the training and be someone you can work with in a therapeutic relationship. If not, you may have to be flexible and try to work with whoever is there. Even if they don't fit your ideal, it still doesn't mean you cannot be helped by this person.

What to ask:

When you finally locate a practitioner, you would do well to ask them the following questions before making an appointment:

What degrees do you have, and are you licensed in this state? (Stay away from the unlicensed. No one regulates them, and you will have no protection if you are improperly treated. In most places, anyone can call themselves a "psychotherapist", whether they've had any training or not).

Do you specialize in treating OCD or trichotillomania (depending upon your diagnosis)? What are your qualifications for this? (Have they had some type of supervised training).

How long have you been in practice? (If they are the only practitioner in your area, this may be less important.)

What is your orientation? (The answer should be cognitive/behavioral treatment)

What techniques do you use? (For behavioral therapy for OCD the answer would have to be Exposure and Response Prevention. For trich, the answer would have to be Habit Reversal Training and Stimulus Control- see below)

What is your fee? Are your services covered by insurance (assuming that the answer to this is an important factor in being able to afford treatment)? Make sure you check with your insurance plan before calling anyone to find out if you have coverage for outpatient mental health treatment. Also be sure to ask if you are only allowed to see practitioners who are members of your plan's network. Insurance companies try to keep this secret, but if they have no one within their network who specializes in your disorder, they have to let you go out of network, and they will even negotiate the specialist's fee, often paying what that specialist usually charges. Don't be afraid to press them on this.

How often would you have to see me? Once per week ought to be enough unless you are in crisis.

On the average, how long will it take for me to see some results with this treatment? You should expect to see at least some results within the first six months, assuming that you are cooperating with treatment instructions.

If you don't like some of the answers you are getting to the above questions, or the practitioner gets defensive about answering them, look elsewhere. A reputable therapist should have no problems answering such questions directly.

What you should know:

Once you have made your first appointment, but before you show up. try to educate yourself about behavioral therapy (BT). Just as you would before buying a large household item, it pays to know something about the product. It is important that you be clear about what is proper behavioral therapy for trich. Over the years, I have had many new patients tell me that they have already tried BT and that it didn't work for them. When questioned further, it would become clear that they hadn't had proper BT at all, but something their therapist told them was BT. Most often, they were taught a simple relaxation exercise which by itself, wasn't enough to do the job. Others have tried hypnosis, and although it usually isn't represented as BT, they mistakenly took it for that.

BT for OCD consists of an approach known as Exposure And Response Prevention. To begin, a careful analysis of all symptoms is made, and a rank ordering of all feared situations known as a hierarchy is established. Based upon this information, an individualized treatment program is created, and behavioral homework assignments are given on a regular basis. Patients are then gradually exposed to larger and larger doses of the thoughts and situations they fear, while resisting their compulsions and staying with the resulting anxiety until it subsides. The therapy may either be self-directed, or done under a therapist's direct supervision in the office or out in the community. I tend to favor self-directed treatment, as it encourages people to be more independent and to eventually become their own therapists. It is a lot closer to real life than having someone standing over you and telling you what to do.

At the present time, proper BT for trich consists of what is known as Habit Reversal Training (HRT), as well as Stimulus Control (SC). HRT is composed of four major parts, together with some extra bells and whistles thrown in to keep you motivated and on track. These extras may vary from therapist to therapist. The four parts of HRT are:

Relaxation training to reduce tensions that lead to pulling, and to help you center yourself when you get the urge to pull.

Breathing exercises to be done along with the relaxation, to increase the relaxationand to further center yourself

A muscle tensing exercise performed with the hands and forearms that is incompatible with pulling.

HRT may be done on an individual basis, or as group treatment. While space does not permit me to give you a really complete rundown on HRT here, you can call or write to TLC to get reprints of previously published articles on behavioral therapy. My article in a previous issue of In Touch (#3 for 1992) gives you a rundown on HRT, and will help you to spot the genuine article when it is being offered.

Actually, good therapy for trich should really offer you more than just HRT and SC. It should take a close look at all aspects of your life: your past history, your working life, your relationships, your general health, your philosophy of life (yes, you have one, everyone does), your spiritual life, the ways in which trich has had an impact on your life, and especially your attitudes toward trich itself and how you view yourself in regard to the disorder. Some people have been so stigmatized by the disorder that this, in itself, needs to be treated before you can even begin doing the HRT. If some of these issues aren't looked into and dealt with, your treatment may never get off the ground due to a lack of motivation or belief in your ability to recover.

There are a number of things which you should look for in a therapist, and some you should beware of. Look for a therapist who:

listens to you, answers your questions, and doesn't just talk at you.

answers your calls in a timely way and is reasonably available to you.

uses the latest accepted treatments that are recognized by leaders in the field.

not only teaches you techniques to get recovered, but also those necessary to stay recovered. They will show you how to realistically accept the inevitable slip-up and still keep going.

helps you to grow into the role of being your own therapist - that is, someone who is responsible for their own recovery and who ultimately learns to depend upon themselves.

doesn't just plug you into a "one size fits all" treatment program, but instead treats you as an individual and tailors (as much as possible) the various techniques they have to fit your particular needs.

if they are the only one in your area and do not have the training, are at least willing to learn about it on your behalf, and to give it try.

Beware of the therapist who:

has you come for an excessive number of visits, or seems to keep you coming to them without any kind of endpoint to the treatment

simply chats with you at every visit but never seems to really work on anything.

keeps you dependent upon them rather than teaching you to depend upon yourself.

is flatly opposed to the use of medication rather than having an open mind about it.

guarantees you results or promises a 'cure' (if something sounds too good to be true, it probably is).

uses methods that neither you nor anyone else has ever heard of

uses methods for which there is no scientific evidence

tells you that your hairpulling is really the result of some other deep unconscious psychological conflict, and that this other problem must be worked out first.

assigns homework that you find really distasteful, humiliating, or degrading.

makes comments or observations that you find embarrassing or humiliating.

keeps telling you that they will eventually get around to the behavioral therapy, but never seems to do so.

Whatever it takes to find a recovery, never give up. In pursuing a recovery, persistence is everything. As long as you keep trying, there is always a good chance that you will succeed. I have rarely seen someone fail to succeed who has stubbornly kept at it. There really are resources out there if you look for them.

If you would like to read more about what Dr. Penzel has to say about OCD, take a look at his self-help book, "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000) You can learn more about it at www.ocdbook.com .

If Trichotillomania is your problem, take a look at Dr. Penzel's other self-help book, "The Hair-Pulling Problem: A Complete Guide to Trichotillomania," (Oxford University Press, 2003). You can learn more about this book at www.trichbook.com